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John J. Albertini, MD; Gary H. Lyman, MD, MPH; Charles Cox, MD; Tim Yeatman, MD; Ludovico Balducci, MD; NiNi Ku, MD; Steve Shivers, PhD; Claudia Berman, MD; Karen Wells, MD; David Rapaport, MD; Alan Shons, MD; John Horton, MB, ChB; Harvey Greenberg, MD; Santo Nicosia, MD; Robert Clark, MD; Alan Cantor, PhD; Douglas S. Reintgen, MD

JAMA. 1996;276(22):1818-1822.

Abstract
Objective.
—To identify the sentinel lymph node(s) (SLN[s]) (the first node[s] draining the primary tumor in the regional lymphatic basin) in patients with invasive breast cancer and to test the hypothesis that the histologic characteristics of the SLN predict the histologic characteristics of the remaining lymph nodes in the axilla.

Design.
—A prospective trial.

Participants.
—Sixty-two patients with newly diagnosed invasive breast cancers.

Intervention.
—Patients underwent intraoperative lymphatic mapping using a combination of a vital blue dye and filtered technetium-labeled sulfur colloid. The SLN was identified and removed, followed by a definitive cancer operation, including a complete axillary node dissection.

Main Outcome Measure.
—The metastatic distribution in the axilla was determined in patients with occult nodal disease.

Results.
—The SLN was successfully identified in 57 (92%) of 62 patients using the 2 lymphatic mapping procedures. After localization, 18 patients (32%) were found to have metastatic disease, and the SLN tested positive in all 18 patients. There were no "skip" metastases, defined as an SLN that tested negative with higher nodes that tested positive. In 12 (67%) of 18 patients with metastatic disease, the SLN was the only site of disease. The metastatic distribution significantly favored SLN involvement. Among subjects with discordant nodal involvement, the probability of observing the distribution of SLN involvement by chance is very small (P<.001).

Conclusions.
—This study confirms that lymphatic mapping is technically possible in the patient with breast cancer and that the histologic characteristics of the SLN probably reflect the histologic characteristics of the rest of the axillary lymph nodes. The procedure also allows the pathologist to focus the histologic examination on 1 or 2 nodes, potentially increasing the yield of positive dissections and the accuracy of staging.

Author Affiliations
From the Comprehensive Breast Cancer Program, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa.

Footnotes
Reprints: Douglas S. Reintgen, MD, Cutaneous Oncology, Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL 33612-9497.

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